Express Scripts Medicare (PDP) 2015 Formulary (List of Covered Drugs)

Transcription

1 Express Scripts Medicare (PDP) 205 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 5053, v6 This formulary was updated on 08/06/204. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Express Scripts Insurance Company or Medco Containment Life Insurance Company. When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of August 6, 204. For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January, 206, and from time to time during the year. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. EME969 CRP F0HP3X5B

2 What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of covered Medicare Part D drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at or contact Customer Service. Express Scripts Medicare will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug on our 205 formulary that was covered at the beginning of the year, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 205 coverage year, except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our plan s formulary, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If Express Scripts Medicare removes drugs from our formulary, adds prior authorization, quantity limits, and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective. If the Food and Administration (FDA) determines that a drug on our formulary is unsafe, or if the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who are taking the drug. This enclosed formulary is current as of the date indicated on the front cover. To get updated information about the drugs covered, please visit us on the Web or contact our Customer Service department using the information provided on the front and back covers of this formulary. If there are any additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time after the changes take effect. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. EME969 CRP i

3 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 60. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the Name column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at or contact Customer Service. You can ask us to make an exception to these restrictions or limits. See the section How do I request an exception to the formulary? on the following page for information about how to request an exception. EME969 CRP ii

4 What if my drug is not on the formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that your drug is not covered, you have two options: You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request a formulary exception so that the plan will cover the drug you are taking. How do I request an exception to the formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting an exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Generally, your request for an exception will only be approved if the alternative drugs that are included in the plan formulary, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. EME969 CRP iii

5 How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document. Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year. For each of your drugs that is not on our formulary, or if your ability to get drugs is limited, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for at least 30 days, or less if your prescription is written for fewer days. In that case, you will be allowed multiple fills to provide up to a total of at least a 30-day supply of the medication. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drug is limited but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency transition supply of that drug (unless you have a prescription written for fewer while you pursue an exception. Other times when we will cover a temporary 3-day transition supply (or less, if you have a prescription written for fewer include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options. EME969 CRP iv

6 Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s, such as CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE and VIAGRA, when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 60. The Name column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of three drug tiers. Each tier may have a different cost-sharing amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. EME969 CRP v

7 s Includes Helpful tips : Generic s 2: Brand s 3: Specialty s This tier includes many commonly prescribed generic drugs and may include other low-cost drugs. This tier includes brand-name drugs as well as some generic drugs. This tier includes high-cost brand-name and generic drugs. Use drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than specialty drugs. To learn more about medications in this tier, you may contact a pharmacist using the information provided on the front and back covers of this formulary. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. If you have general questions about Medicare prescription drug coverage, please call Medicare at.800.medicare ( ), 24 hours a day, 7 days a week. TTY users should call Or visit EME969 CRP vi

8 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan s specific coverage, contact Customer Service using the information provided on the front and back covers of this List of abbreviations LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary. MO: Mail-Order. This prescription drug is available through our home delivery service, as well as through our retail network pharmacies. Consider using home delivery for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover this drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. EME969 CRP vii

9 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 3 PA; MO AMBISOME 3 PA; MO amphotericin b PA; MO CANCIDAS 3 PA; MO clotrimazole mucous membrane fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ; QL (20 ketoconazole oral LAMISIL ORAL GRANULES IN PACKET MYCAMINE INTRAVENOUS RECON SOLN 00 MG MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL Name nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral acyclovir sodium intravenous solution PA adefovir amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 3

10 Name BARACLUDE ORAL TABLET cidofovir 3 PA; MO COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA EPIVIR ORAL SOLUTION EPIVIR HBV ORAL SOLUTION EPZICOM famciclovir foscarnet PA; MO FUZEON ganciclovir sodium INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET 2 2 Name ISENTRESS ORAL TABLET,CHEWAB LE 00 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET MODERIBA MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 400 MG (7)- 400 MG (7) MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 600 MG (7)- 600 MG (7) nevirapine NORVIR OLYSIO 3 PA; MO 2

11 Name PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER ; QL (60 per 80 RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ RIBAPAK DOSE PACK ORAL TABLETS,DOSE PACK MG (28)-MG (28), MG (28)-MG (28), MG (28)-MG (28) RIBASPHERE ORAL CAPSULE RIBASPHERE ORAL TABLET 200 MG RIBASPHERE ORAL TABLET 400 MG RIBASPHERE ORAL TABLET 600 MG 2 ribavirin rimantadine SELZENTRY Name SOVALDI 3 PA; MO stavudine STRIBILD SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG, 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N ; LA ; QL (84 per 80 ; QL (42 per 80 ; QL (600 per 80 TIVICAY TRUVADA TYZEKA valacyclovir ; QL (30 VALCYTE VICTRELIS VIDEX 2 GRAM PEDIATRIC VIRACEPT VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG VIRAZOLE VIREAD 3

12 Name ZIAGEN ORAL SOLUTION zidovudine CEPHALOSPORINS cefaclor cefadroxil cefazolin injection recon soln gram cefazolin injection recon soln 0 gram, 500 mg cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefdinir cefditoren pivoxil oral tablet 200 mg cefepime cefotaxime injection recon soln gram, 2 gram, 500 mg cefotaxime injection recon soln 0 gram cefotetan cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, 2 gram cefoxitin in dextrose, iso-osm cefpodoxime cefprozil Name ceftazidime injection recon soln gram, 6 gram ceftazidime injection recon soln 2 gram ceftriaxone injection recon soln 0 gram ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous 4 cefuroxime axetil cefuroxime sodium injection cefuroxime sodium intravenous cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 00 MG/5 ML, 200 MG/5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWAB LE 2 TEFLARO

13 Name ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin E.E.S. 400 E.E.S. GRANULES ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 250 MG, 333 MG ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG ERYPED 200 ERYPED 400 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG ERYTHROCIN (AS STEARATE) erythromycin oral tablet erythromycin ethylsuccinate oral 2 MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml Name atovaquone erythromycinsulfisoxazole atovaquoneproguanil aztreonam injection recon soln gram BACIIM bacitracin intramuscular BETHKIS (224 per 28 CAPASTAT 2 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate oral 5 clindamycin hcl clindamycin in dextrose 5 % CLINDAMYCIN PEDIATRIC clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN dapsone DARAPRIM

14 Name DORIBAX INTRAVENOUS SUSPENSION FOR RECONSTITUTIO N 500 MG ethambutol gentamicin injection solution 40 mg/ml gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral 2 imipenem-cilastatin INVANZ INJECTION isoniazid injection isoniazid oral mefloquine meropenem intravenous recon soln 500 mg metronidazole oral capsule metronidazole oral tablet metronidazole in nacl (iso-os) Name NEBUPENT 2 PA; MO; QL (6 per 28 neomycin paromomycin PASER PENTAM polymyxin b sulfate PRIFTIN primaquine pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA streptomycin intramuscular STROMECTOL SYNERCID 3 tinidazole tobramycin in % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/00 ml tobramycin sulfate injection solution (280 per 28 TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 MG 6

15 Name XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL PENICILLINS amoxicillin amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin-sulbactam injection recon soln 5 gram ampicillin-sulbactam injection recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection recon soln gram Name nafcillin injection recon soln 0 gram nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml 3 penicillin g sodium penicillin v potassium PFIZERPEN-G INJECTION RECON SOLN 5 MILLION UNIT 7

16 Name piperacillintazobactam intravenous recon soln gram, 4.5 gram QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) ciprofloxacin intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcap sule recon ciprofloxacin oral tablet ciprofloxacin (mixture) ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml levofloxacin intravenous levofloxacin oral levofloxacin in d5w intravenous piggyback 500 mg/00 ml moxifloxacin ofloxacin oral SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazoletrimethoprim Name TETRACYCLINES demeclocycline doxycycline hyclate intravenous doxycycline hyclate oral doxycycline monohydrate oral capsule 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet 50 mg, 50 mg, 75 mg minocycline oral tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG methenamine hippurate nitrofurantoin oral nitrofurantoin macrocrystal oral capsule 50 mg nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim 8

17 Name VANCOMYCIN vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg vancomycin oral ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane intravenous recon soln 250 mg ELITEK INTRAVENOUS RECON SOLN.5 MG FUSILEV KEPIVANCE 3 leucovorin calcium injection recon soln 00 mg, 350 mg leucovorin calcium oral 3 3 mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE Name AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG AFINITOR DISPERZ ALIMTA INTRAVENOUS RECON SOLN 500 MG (60 per 30 3 PA; MO 3 PA; MO anastrozole ARRANON 3 ARZERRA INTRAVENOUS SOLUTION 00 MG/5 ML 3 PA; MO AVASTIN azacitidine AZASAN 2 PA; MO azathioprine PA; MO bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG BUSULFEX 3 CAPRELSA ORAL TABLET 00 MG 3 PA; MO (30 per 30 ; LA 9

18 Name CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N CELLCEPT INTRAVENOUS ; LA; QL (30 per 30 3 PA; MO 2 PA cisplatin cladribine CLOLAR COMETRIQ 3 PA; MO cyclophosphamide oral capsule cyclophosphamide oral tablet cyclosporine intravenous 2 PA PA; MO PA cyclosporine oral PA; MO cyclosporine modified PA; MO cytarabine cytarabine (pf) injection solution 2 gram/20 ml (00 mg/ml) dacarbazine intravenous recon soln 200 mg daunorubicin intravenous solution Name decitabine DOCEFREZ 3 docetaxel intravenous solution 80 mg/4 ml (20 mg/ml) docetaxel intravenous solution 80 mg/8 ml (0 mg/ml) DOXIL doxorubicin intravenous solution 50 mg/25 ml 3 DROXIA ELIGARD 2 PA; MO EMCYT epirubicin intravenous solution 50 mg/25 ml ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML ERIVEDGE (30 per 30 ERWINAZE 3 ETOPOPHOS etoposide intravenous exemestane FARESTON FASLODEX 0

19 Name FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml flutamide FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) gemcitabine intravenous recon soln gram GENGRAF PA; MO GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG GLEEVEC ORAL TABLET 00 MG GLEEVEC ORAL TABLET 400 MG (60 per 30 (40 per 30 (30 per 30 3 PA; MO (60 per 30 HALAVEN HERCEPTIN HEXALEN Name hydroxyurea idarubicin ifosfamide intravenous recon soln gram IMBRUVICA (20 per 30 INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG irinotecan intravenous solution 00 mg/5 ml 3 PA; MO (20 per 30 ISTODAX IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG JAKAFI ORAL TABLET 25 MG 3 PA; MO (60 per 30 JEVTANA KADCYLA INTRAVENOUS RECON SOLN 00 MG letrozole LEUKERAN leuprolide

20 Name lomustine LUPRON DEPOT 3 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT.25 MG, 5 MG 3 PA; MO 3 PA; MO 3 PA; MO 3 PA; MO LYSODREN MATULANE megestrol oral suspension 400 mg/0 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan 3 (20 per 30 (30 per 30 mercaptopurine methotrexate sodium oral methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution PA; MO PA PA; MO Name mitomycin intravenous recon soln 20 mg mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium PA; MO PA; MO NEXAVAR 3 PA; MO; LA NILANDRON NULOJIX 3 PA; MO octreotide acetate injection solution,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 00 mcg/ml, 200 mcg/ml, 50 mcg/ml ONCASPAR oxaliplatin intravenous solution 00 mg/20 ml paclitaxel PERJETA POMALYST PROGRAF INTRAVENOUS RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET MG 2 PA; MO 2 PA; MO 2 PA; MO 2

21 Name RAPAMUNE ORAL TABLET 2 MG 3 PA; MO REVLIMID 3 PA; MO; LA RITUXAN 3 PA; MO SANDOSTATIN LAR DEPOT SIGNIFOR 3 PA; MO SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 PA; MO sirolimus PA; MO SOLTAMOX SPRYCEL ORAL TABLET 00 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 40 MG SPRYCEL ORAL TABLET 70 MG 3 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 28 SUTENT ORAL CAPSULE 2.5 MG SUTENT ORAL CAPSULE 25 MG SUTENT ORAL CAPSULE 50 MG 3 PA; MO (60 per 30 (30 per 30 Name SYLVANT INTRAVENOUS RECON SOLN 00 MG SYNRIBO TABLOID tacrolimus oral capsule 0.5 mg, mg tacrolimus oral capsule 5 mg TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG PA; MO 3 PA; MO (80 per 30 (20 per 30 tamoxifen TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG 3 PA; MO (30 per 30 TARGRETIN TASIGNA ORAL CAPSULE 50 MG TASIGNA ORAL CAPSULE 200 MG 3 PA; MO (2 per 28 THALOMID 3 PA; MO TOPOSAR topotecan intravenous recon soln TORISEL 3

22 Name TREANDA INTRAVENOUS RECON SOLN 00 MG TRELSTAR TRELSTAR DEPOT TRELSTAR LA 3 tretinoin (chemotherapy) 3 TRISENOX TYKERB 3 PA; MO; LA; QL (80 per 30 VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (20 MG/ML) 3 PA; MO VELCADE vinblastine intravenous solution vincristine intravenous solution mg/ml vinorelbine intravenous solution 50 mg/5 ml VOTRIENT (20 per 30 XALKORI ORAL CAPSULE 200 MG XALKORI ORAL CAPSULE 250 MG 3 PA; MO (60 per 30 Name XTANDI (20 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) ZANOSAR ZELBORAF (240 per 30 ZOLINZA ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 2 PA; MO 3 PA; MO ZYKADIA (50 per 30 ZYTIGA (20 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG 4

23 Name APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG carbamazepine CELONTIN clonazepam PA; MO diazepam rectal PA; MO DILANTIN divalproex EPITOL ethosuximide felbamate fosphenytoin injection solution 00 mg pe/2 ml FYCOMPA gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet GABITRIL ORAL TABLET 2 MG, 6 MG lamotrigine oral tablet Name lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible levetiracetam intravenous levetiracetam oral solution 00 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA 2 PA; MO ONFI 2 PA; MO oxcarbazepine PEGANONE phenobarbital phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium intravenous solution phenytoin sodium extended POTIGA primidone SABRIL ; LA 5

24 Name TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone 2 entacapone NEUPRO pramipexole ropinirole Name selegiline hcl MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection ERGOMAR MIGERGOT naratriptan ; QL (8 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution ; QL (8 per 28 ; QL (36 per 28 ; QL (8 per 28 ; QL (6 per 28 ; QL (6 per 28 zolmitriptan ; QL (8 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 3 PA; MO; LA COPAXONE SUBCUTANEOUS SYRINGE KIT (30 per 30 6

25 Name donepezil EXELON TRANSDERMAL 2 ST; MO galantamine GILENYA 3 PA; MO NAMENDA 2 PA; MO NAMENDA TITRATION PAK 2 PA; MO NUEDEXTA rivastigmine tartrate TECFIDERA 3 PA; MO TYSABRI 3 PA; MO; LA XENAZINE 3 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine PA; MO dantrolene GABLOFEN INTRATHECAL SOLUTION 0,000 MCG/20ML (500 MCG/ML), 40,000 MCG/20ML (2,000 MCG/ML) GABLOFEN INTRATHECAL SYRINGE 50 MCG/ML ( ML) LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML 2 PA; MO 2 PA; MO 2 PA; MO Name LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide 2 PA tizanidine NARCOTIC ANALGESICS acetaminophencodeine oral solution 300 mg-30 mg /2.5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine injection syringe buprenorphine sublingual tablet, sublingual 2 mg buprenorphine sublingual tablet, sublingual 8 mg codeine sulfate oral tablet QL (4500 per 30 ; QL (360 ; QL (80 QL (267 per 30 ; QL (300 ; QL (75 ; QL (80 7

26 Name DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML DURAMORPH (PF) INJECTION SOLUTION MG/ML ENDOCET ORAL TABLET MG, MG, MG ; QL (4000 QL (2000 per 30 ; QL (360 ENDODAN ; QL (360 fentanyl citrate buccal lozenge on a handle,200 mcg fentanyl citrate buccal lozenge on a handle,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl patches transdermal patch 72 hour 00 mcg/hr (39 per 30 (29 per 30 (20 per 30 (6 per 30 (77 per 30 (58 per 30 ; QL (9 per 30 Name fentanyl patches transdermal patch 72 hour 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral tablet mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 2 mg, 8 mg hydromorphone oral tablet extended release 24 hr 6 mg hydromorphone (pf) injection solution 0 mg/ml ; QL (0 ; QL (5550 ; QL (360 ; QL (50 ; QL (300 ; QL (80 ; QL (60 ; QL (60 ; QL (20 ibuprofen-oxycodone ; QL (28 levorphanol tartrate ; QL (20 8

27 Name LORCET (HYDROCODONE) QL (360 per 30 LORCET HD ; QL (360 LORCET PLUS QL (360 per 30 LORTAB ; QL (360 LORTAB ; QL (360 LORTAB ; QL (360 methadone injection QL (60 per 30 methadone oral solution 0 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg methadone oral tablet 5 mg morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr 20 mg ; QL (600 ; QL (200 ; QL (20 ; QL (240 QL (000 per 30 QL (500 per 30 ; QL (50 Name morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 0 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 00 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution ; QL (60 ; QL (90 ; QL (60 ; QL (75 ; QL (900 morphine oral tablet ; QL (80 morphine oral tablet extended release 00 mg morphine oral tablet extended release 5 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg morphine concentrate oral solution oxycodone oral capsule ; QL (60 ; QL (20 ; QL (30 ; QL (00 ; QL (300 ; QL (360 9

28 Name oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg ; QL (80 ; QL (200 ; QL (80 ; QL (34 ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 2 hr 30 mg oxymorphone oral tablet extended release 2 hr 40 mg ; QL (200 ; QL (80 ; QL (90 ; QL (67 ; QL (50 REPREXAIN ; QL (50 VICODIN ; QL (360 VICODIN ES ; QL (360 Name VICODIN HP ; QL (360 ZAMICET ; QL (5550 NON-NARCOTIC ANALGESICS butorphanol tartrate injection solution mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal PA; MO; QL (90 per 30 ; QL (720 ; QL (360 ; QL (40 CELEBREX diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops oxycodoneacetaminophen buprenorphinenaloxone diclofenacmisoprostol diflunisal etodolac fenoprofen oral tablet flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg 20

29 Name ketoprofen meclofenamate oral mefenamic acid meloxicam oral suspension meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg ; QL (30 nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection syringe mg/ml ; QL (200 ; QL (00 naltrexone naproxen naproxen sodium oral tablet 275 mg, 550 mg oxaprozin piroxicam sulindac oral tolmetin tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr 00 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg ; QL (30 ; QL (30 Name tramadolacetaminophen ; QL (240 VOLTAREN GEL 2 ST; MO ZUBSOLV 2 PA; MO; QL (90 per 30 PSYCHOTHERAPEUTIC DRUGS ABILIFY INTRAMUSCULA R ABILIFY ORAL SOLUTION ABILIFY ORAL TABLET 0 MG ABILIFY ORAL TABLET 5 MG ABILIFY ORAL TABLET 2 MG ABILIFY ORAL TABLET 20 MG ABILIFY ORAL TABLET 30 MG ABILIFY ORAL TABLET 5 MG ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 0 MG ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 5 MG ; QL (90 ; QL (60 ; QL (450 ; QL (60 ; QL (30 ; QL (80 ; QL (90 ; QL (60 2

30 Name ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 300 MG alprazolam oral tablet amitriptyline PA; MO amoxapine AMPHETAMINE SALT COMBO BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET 20 MG BRINTELLIX ORAL TABLET 5 MG bupropion hcl oral tablet bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 50 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg ; QL (60 ; QL (30 ; QL (20 ; QL (20 ; QL (90 ; QL (60 ; QL (90 Name bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (60 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg ; QL (20 ; QL (60 ; QL (30 clomipramine PA; MO clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium clozapine oral tablet PA; MO desipramine oral dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine diazepam oral solution 5 mg/5 ml PA; MO diazepam oral tablet PA; MO DIAZEPAM INTENSOL PA; MO 22

31 Name doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg ; QL (80 ; QL (20 ; QL (60 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (20 eszopiclone ST; MO; QL (30 per 30 FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG, 8 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG ; QL (720 ; QL (90 ; QL (60 ; QL (360 ; QL (80 Name FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 50 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg ; QL (20 2 QL (8 per ST; MO; QL (28 per 28 2 ST; MO; QL (30 per 30 2 ST; MO; QL (80 per 30 2 ST; MO; QL (90 per 30 2 ST; MO; QL (45 per 30 ; QL (240 ; QL (60 23

32 Name fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg fluoxetine oral tablet 20 mg fluphenazine decanoate ; QL (4 per 28 ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 00 mg fluvoxamine oral capsule,extended release 24hr 50 mg fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULA R ; QL (90 ; QL (60 ; QL (90 ; QL (360 ; QL (80 guanidine haloperidol haloperidol decanoate haloperidol lactate imipramine hcl PA; MO imipramine pamoate PA; MO Name INVEGA ORAL TABLET EXTENDED RELEASE 24HR.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG ; QL (240 ; QL (20 ; QL (60 ; QL (4 ; QL (30 ; QL (240 ; QL (20 24

33 Name LATUDA ORAL TABLET 60 MG, 80 MG ; QL (60 lithium carbonate lithium citrate lorazepam oral tablet LORAZEPAM INTENSOL PA; MO PA; MO loxapine succinate maprotiline MARPLAN METADATE ER methamphetamine methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr mirtazapine modafinil PA; MO nefazodone Name nortriptyline olanzapine intramuscular olanzapine oral tablet 0 mg olanzapine oral tablet 5 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 0 mg olanzapine oral tablet,disintegrating 5 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (60 ; QL (30 ; QL (240 ; QL (20 ; QL (8 ; QL (60 ; QL (30 ; QL (20 ORAP oxazepam PA; MO paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg ; QL (80 ; QL (90 ; QL (60 ; QL (45 25

34 Name paroxetine hcl oral tablet extended release 24 hr 2.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION ; QL (80 ; QL (90 ; QL (60 perphenazine perphenazineamitriptyline PA; MO phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG 2 ST; MO; QL (20 per 30 2 ST; MO; QL (240 per 30 PROCENTRA protriptyline quetiapine oral tablet 00 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg ; QL (240 ; QL (20 ; QL (902 Name quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 2.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg ; QL (8 ; QL (60 ; QL (480 ; QL (480 ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 ; QL (920 26

35 Name risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 ROZEREM ; QL (30 SAPHRIS SUBLINGUAL TABLET, SUBLINGUAL 0 MG SAPHRIS SUBLINGUAL TABLET, SUBLINGUAL 5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET, SUBLINGUAL 0 MG ; QL (60 ; QL (20 ; QL (60 Name SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET, SUBLINGUAL 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 00 mg sertraline oral tablet 25 mg ; QL (20 ; QL (6 ; QL (20 ; QL (8 ; QL (60 ; QL (480 ; QL (60 ; QL (240 27

36 Name sertraline oral tablet 50 mg ; QL (20 STRATTERA SURMONTIL 2 PA; MO temazepam PA; MO thioridazine thiothixene tranylcypromine trazodone trifluoperazine venlafaxine oral capsule,extended release 24hr 50 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 00 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg ; QL (60 ; QL (80 ; QL (90 ; QL (90 VERSACLOZ 3 LA VIIBRYD ORAL TABLET 0 MG VIIBRYD ORAL TABLET 20 MG ; QL (270 ; QL (80 ; QL (50 ; QL (20 ; QL (60 Name VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK ; QL (30 ; QL (30 XYREM ; LA zaleplon oral capsule 0 mg zaleplon oral capsule 5 mg ZENZEDI ORAL TABLET 0 MG, 5 MG ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg ST; MO; QL (60 per 30 ST; MO; QL (30 per 30 ; QL (240 ; QL (20 ; QL (80 ; QL (60 zolpidem ST; MO; QL (30 per 30 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone oral tablet 200 mg, 400 mg PA; MO flecainide 28

37 Name mexiletine PACERONE procainamide injection solution 00 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate SORINE ORAL TABLET 20 MG, 60 MG, 80 MG SORINE ORAL TABLET 240 MG sotalol oral tablet 60 mg, 240 mg, 80 mg SOTALOL AF ORAL TABLET 20 MG TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol oral AFEDITAB CR amiloride amlodipine atenolol Name benazepril betaxolol oral bisoprolol fumarate bumetanide candesartan captopril amiloridehydrochlorothiazide amlodipinebenazepril atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide CARTIA XT carvedilol chlorothiazide chlorothiazide sodium chlorthalidone clonidine ; QL (4 per 28 clonidine hcl oral tablet CLORPRES ORAL TABLET 0.-5 MG CLORPRES ORAL TABLET MG DEMSER 29

38 Name DIBENZYLINE DILT-XR diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 mg diltiazem hcl oral tablet doxazosin oral tablet mg, 2 mg, 4 mg doxazosin oral tablet 8 mg ; QL (30 ; QL (60 DUTOPROL enalapril maleate eplerenone eprosartan felodipine fosinopril furosemide injection solution furosemide oral Name hydralazine hydrochlorothiazide indapamide irbesartan isradipine labetalol intravenous solution labetalol oral lisinopril losartan enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide MATZIM LA methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate oral minoxidil oral moexipril metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide 30

39 Name nadolol nicardipine NIFEDICAL XL nifedipine oral tablet extended release 24hr nimodipine nisoldipine perindopril erbumine pindolol prazosin propranolol intravenous propranolol oral quinapril ramipril REMODULIN 3 PA; MO; LA spironolactone TAZTIA XT telmisartan Name terazosin oral capsule mg, 2 mg, 5 mg terazosin oral capsule 0 mg ; QL (30 ; QL (60 timolol maleate oral torsemide intravenous solution 20 mg/2 ml (0 mg/ml) torsemide oral trandolapril nadololbendroflumethiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid triamterenehydrochlorothiazid valsartanhydrochlorothiazide verapamil intravenous solution verapamil oral CARDIAC GLYCOSIDES digoxin oral LANOXIN ORAL TABLET 87.5 MCG LANOXIN ORAL TABLET 62.5 MCG 2 COAGULATION THERAPY AGGRENOX BRILINTA cilostazol clopidogrel 3

40 Name dipyridamole oral EFFIENT ELIQUIS enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 00 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 20 mg/0.8 ml, 50 mg/ml fondaparinux subcutaneous syringe 0 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml heparin (porcine) injection solution heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml) Name heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml JANTOVEN pentoxifylline PROMACTA 3 PA; MO; LA tranexamic acid intravenous warfarin XARELTO LIPID/CHOLESTEROL LOWERING AGENTS ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR, MG, MG ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR, MG, MG amlodipineatorvastatin ; QL (60 ; QL (30 ; QL (30 atorvastatin ; QL (30 CHOLESTYRAMI NE LIGHT ORAL POWDER IN PACKET 32

41 Name colestipol oral granules colestipol oral tablet fenofibrate oral tablet fenofibrate micronized fenofibrate nanocrystallized fenofibric acid (choline) fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg ; QL (30 ; QL (60 gemfibrozil oral JUXTAPID ; LA KYNAMRO ; LA lovastatin oral tablet 0 mg lovastatin oral tablet 20 mg, 40 mg niacin oral tablet extended release 24 hr omega-3 acid ethyl esters ; QL (30 ; QL (60 pravastatin ; QL (30 PREVALITE ORAL POWDER simvastatin ; QL (30 WELCHOL Name ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA VECAMYL 3 NITRATES isosorbide dinitrate isosorbide mononitrate NITRO-BID nitroglycerin intravenous nitroglycerin transdermal nitroglycerin translingual spray,non-aerosol PA NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 0 mg acitretin oral capsule 7.5 mg, 25 mg calcipotriene calcipotrienebetamethasone calcitriol topical selenium sulfide topical suspension 33

42 Name BURN THERAPY silver sulfadiazine SSD MISCELLANEOUS DERMATOLOGICALS 8-MOP ammonium lactate CARAC diclofenac sodium topical gel fluorouracil topical imiquimod methoxsalen rapid 3 OXSORALEN PANRETIN podofilox PROTOPIC 2 PA; MO PRUDOXIN REGRANEX ; QL (5 UVADEX 2 ZYCLARA THERAPY FOR ACNE adapalene PA; MO AMNESTEEM AVITA TOPICAL CREAM PA; MO CLARAVIS clindamycin phosphate topical Name clindamycin-benzoyl peroxide topical gel ERY PADS erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycinbenzoyl peroxide metronidazole topical cream metronidazole topical gel metronidazole topical lotion MYORISAN TAZORAC 2 PA; MO tretinoin topical PA; MO ZENATANE TOPICAL ANESTHETICS lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine (pf) injection solution 0 mg/ml ( %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) PA; MO 34

43 Name lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % lidocaine hcl mucous membrane solution 4 % lidocaine-prilocaine topical cream TOPICAL ANTIBACTERIALS gentamicin topical mafenide acetate mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM TOPICAL ANTIFUNGALS ciclopirox clotrimazole topical econazole topical ketoconazole topical KETODAN KIT NYAMYC nystatin topical Name clotrimazolebetamethasone nystatintriamcinolone NYSTOP PEDI-DRI TOPICAL ANTIVIRALS acyclovir topical DENAVIR ZOVIRAX TOPICAL CREAM TOPICAL CORTICOSTEROIDS ALA-CORT alclometasone amcinonide APEXICON E betamethasone dipropionate betamethasone valerate betamethasone, augmented clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution 35

44 Name clobetasol-emollient topical cream desonide desoximetasone diflorasone fluocinolone fluocinonide topical cream 0. % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution FLUOCINONIDE-E fluticasone topical halobetasol propionate hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone butyr-emollient hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution Name hydrocortisone valerate mometasone prednicarbate triamcinolone acetonide topical TRIDERM TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES lindane malathion permethrin topical cream spinosad DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg ; QL (30 anagrelide 36

45 Name ARALAST NP INTRAVENOUS RECON SOLN 500 MG ; LA CARBAGLU ; LA cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 0 % & 0.2 % nacl dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %- lactated ringers 2 PA 2 2 Name dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride disulfiram etidronate disodium EXJADE ORAL TABLET, DISPERSIBLE 25 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG ; LA ; LA FERRIPROX INCRELEX ; LA KIONEX ORAL POWDER levocarnitine intravenous levocarnitine oral tablet levocarnitine (with sugar) midodrine ORFADIN ; LA pilocarpine hcl oral PROLASTIN-C ; LA RAVICTI RENVELA ORAL TABLET riluzole 37

46 Name sodium chloride irrigation sodium chloride 0.9 % intravenous parenteral solution sodium phenylbutyrate SODIUM POLYSTYRENE (SORB FREE) SYPRINE THIOLA water for irrigation, sterile zoledronic acidmannitol-water intravenous solution SMOKING DETERRENTS PA; MO BUPROBAN CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX CHANTIX STARTING MONTH PAK 2 NICOTROL NICOTROL NS 2 Name EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal ; QL (60 chlorhexidine gluconate mucous membrane ipratropium bromide nasal ; QL (30 PERIOGARD triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS ACETASOL HC acetic acid otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES A-HYDROCORT cortisone 38

47 Name dexamethasone oral elixir dexamethasone oral tablet DEXAMETHASON E INTENSOL dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone acetate methylprednisolone sodium succ injection recon soln 25 mg methylprednisolone sodium succ injection recon soln 40 mg MILLIPRED ORAL TABLET prednisolone sodium phosphate oral solution 5 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) PA; MO PA; MO Name prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml) prednisone oral solution prednisone oral tablet PREDNISONE INTENSOL triamcinolone acetonide injection suspension 0 mg/ml triamcinolone acetonide injection suspension 40 mg/ml PA; MO VERIPRED 20 ANTITHYROID AGENTS methimazole propylthiouracil DIABETES THERAPY acarbose oral tablet 00 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ALCOHOL PADS 2 BYDUREON SUBCUTANEOUS SUSPENSION,EXT ENDED REL RECON ; QL (90 ; QL (360 ; QL (80 2 PA; MO; QL (4 per 28 39

48 Name BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML 2 PA; MO; QL (2.4 per 30 2 PA; MO; QL (.2 per 30 CYCLOSET ; QL (80 gauze pads 2 x 2 2 glimepiride oral tablet mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 0 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 0 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg ; QL (240 ; QL (20 ; QL (60 ; QL (20 ; QL (240 ; QL (60 ; QL (240 ; QL (20 ; QL (240 Name glipizide-metformin oral tablet mg, mg GLUCAGEN 2 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY ; QL (20 HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N PEN HUMULIN R HUMULIN R U-500 "CONCENTRATED " insulin pen needle 40

49 Name insulin syringe (disp) u ml insulin syringe (disp) u-00 ml insulin syringe (disp) u-00 /2 ml 2 INVOKANA ; QL (30 JANUMET ; QL (60 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-,000 MG ; QL (30 ; QL (60 JANUVIA ; QL (30 JENTADUETO ; QL (60 LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH metformin oral tablet,000 mg metformin oral tablet 500 mg ; QL (75 ; QL (50 Name metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr,000 mg nateglinide oral tablet 20 mg nateglinide oral tablet 60 mg needles, insulin disp.,safety ; QL (90 ; QL (20 ; QL (75 ; QL (75 ; QL (90 ; QL (80 NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL 2 pioglitazone ; QL (30 pioglitazoneglimepiride pioglitazonemetformin ; QL (30 ; QL (90 PROGLYCEM 4

50 Name repaglinide oral tablet 0.5 mg repaglinide oral tablet mg repaglinide oral tablet 2 mg ; QL (960 ; QL (480 ; QL (240 RIOMET ; QL (765 SYMLINPEN 20 2 PA; MO; QL (8.9 per 30 SYMLINPEN 60 2 PA; MO; QL (0.5 per 30 tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (20 ; QL (60 tolbutamide ; QL (80 TRADJENTA ; QL (30 VGO 20 VGO 30 VGO 40 MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 3 PA; MO ANDROGEL 2 PA; MO ANDROXY cabergoline ; QL (6 per 28 calcitonin (salmon) Name calcitriol intravenous calcitriol oral CEREZYME chorionic gonadotropin, human PA; MO danazol oral desmopressin injection desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol intravenous doxercalciferol oral ELAPRASE ELELYSO FABRAZYME INTRAVENOUS RECON SOLN 35 MG FORTICAL KUVAN ORAL TABLET,SOLUBL E ; LA LUMIZYME ; LA METHITEST MIACALCIN INJECTION MYALEPT 3 PA; MO; LA MYOZYME NAGLAZYME ; LA 42

51 Name NOVAREL PA; MO oxandrolone oral tablet 0 mg oxandrolone oral tablet 2.5 mg pamidronate intravenous solution 3 PA; MO PA; MO paricalcitol SAMSCA ORAL TABLET 5 MG SAMSCA ORAL TABLET 30 MG SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG (30 per 30 (60 per 30 SOMAVERT ; LA SYNAREL testosterone cypionate testosterone enanthate VPRIV ZAVESCA ; LA ZEMPLAR INTRAVENOUS zoledronic acid intravenous solution THYROID HORMONES levothyroxine oral Name LEVOXYL liothyronine intravenous liothyronine oral THYROLAR- THYROLAR-/2 THYROLAR-/4 THYROLAR-2 THYROLAR-3 UNITHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe dicyclomine diphenoxylateatropine glycopyrrolate loperamide oral capsule MISCELLANEOUS GASTROINTESTINAL AGENTS ALOXI ; QL (0 43

52 Name AMITIZA balsalazide budesonide oral CANASA CESAMET 3 PA; MO CHENODAL 3 PA; MO; LA COLOCORT COMPRO CONSTULOSE CORTIFOAM CREON cromolyn oral CYSTADANE DIPENTUM dronabinol oral capsule 0 mg dronabinol oral capsule 2.5 mg, 5 mg EMEND INTRAVENOUS 3 PA; MO PA; MO EMEND ORAL 2 PA; MO ENULOSE GAVILYTE-C GAVILYTE-G GAVILYTE-N GENERLAC granisetron intravenous solution mg/ml ( ml) granisetron oral PA; MO Name granisetron (pf) intravenous solution 00 mcg/ml GRANISOL PA; MO hydrocortisone rectal lactulose oral solution 0 gram/5 ml LIALDA LINZESS LOTRONEX meclizine oral tablet mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl oral ondansetron PA; MO ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron hcl (pf) injection solution peg electrolytes oral recon soln gram PA; MO PA PA; MO PENTASA 44

53 Name polyethylene glycol 3350 oral powder prochlorperazine prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral PROCTO-PAK PROCTOZONE-HC RECTIV RELISTOR REMICADE 3 PA; MO SUCRAID sulfasalazine oral tablet SULFAZINE EC TRANSDERM- SCOP TRILYTE WITH FLAVOR PACKETS UCERIS ursodiol VIOKACE Name ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT ULCER THERAPY amoxicilclarithromylansopraz CARAFATE ORAL SUSPENSION ; QL (2 cimetidine esomeprazole sodium famotidine oral suspension famotidine oral tablet 20 mg, 40 mg 45 famotidine (pf) famotidine (pf)-nacl (iso-os) lansoprazole oral capsule,delayed release(dr/ec) 5 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg ; QL (30 misoprostol

54 Name nizatidine omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg omeprazole-sodium bicarbonate oral capsule 20-. mggram omeprazole-sodium bicarbonate oral capsule 40-. mggram pantoprazole intravenous pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ; QL (30 ; QL (30 ; QL (30 rabeprazole ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 50 mg, 300 mg Name sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARCALYST 3 PA; MO AVONEX INTRAMUSCULA R KIT AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE AVONEX ADMINISTRATIO N PACK BETASERON SUBCUTANEOUS KIT (4 per 28 (4 per 28 (4 per 28 (4 per 28 (5 per 28 EGRIFTA 3 PA; MO ILARIS (PF) 3 PA; MO; LA INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE 46

55 Name MOZOBIL NEULASTA (2 NEUMEGA NEUPOGEN INJECTION SOLUTION 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE OMNITROPE SUBCUTANEOUS CARTRIDGE OMNITROPE SUBCUTANEOUS RECON SOLN 3 PA; MO 3 PA; MO 2 PA; MO 3 PA; MO PEGASYS ; QL (4 per 28 PEGASYS CONVENIENCE PACK PEGASYS PROCLICK ; QL (4 per 28 ; QL (4 per 28 PEGINTRON ; QL (4 per 28 PEGINTRON REDIPEN PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML ; QL (4 per 28 2 PA; MO Name PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML 3 PA; MO PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK (6 per 28 (6 per 28 (2 per 28 (2 per 28 SAIZEN 3 PA; MO SAIZEN CLICK.EASY 3 PA; MO SYLATRON VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION ATGAM 3 PA bcg vaccine, live (pf) 2 BOOSTRIX TDAP 47

56 Name BOTOX INJECTION RECON SOLN 00 UNIT CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 3 GRAM CERVARIX VACCINE (PF) 2 PA; MO 3 PA COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) INTRAMUSCULA R SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE 2 PA; MO 2 PA; MO 2 PA fomepizole GAMASTAN S/D GAMUNEX-C INJECTION SOLUTION GRAM/0 ML (0 %) GARDASIL (PF) INTRAMUSCULA R SUSPENSION 2 PA; MO Name HAVRIX (PF) INTRAMUSCULA R SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION IPOL INJECTION SUSPENSION 2 2 IXIARO (PF) M-M-R II (PF) MENACTRA (PF) MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y- W-35-DIP (PF) PEDVAX HIB (PF) PRIVIGEN 3 PA; MO PROQUAD (PF) 2 RABAVERT (PF) RAGWITEK 48

57 Name RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 0 MCG/ML, 40 MCG/ML ROTARIX 2 ROTATEQ VACCINE tetanus toxoid,adsorbed (pf) tetanus-diphtheria toxoids-td TWINRIX (PF) INTRAMUSCULA R SUSPENSION TYPHIM VI INTRAMUSCULA R SOLUTION VAQTA (PF) INTRAMUSCULA R SUSPENSION 25 UNIT/0.5 ML 2 PA; MO 2 2 VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol ALOPRIM colchicineprobenecid COLCRYS Name probenecid ULORIC 2 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 0 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (286 ; QL (30 ; QL (4 per 28 FORTEO (2.4 per 28 ibandronate intravenous 2 PA; MO ibandronate oral ; QL ( per 30 PROLIA 2 PA; MO raloxifene risedronate ; QL ( per 30 OTHER RHEUMATOLOGICALS ACTEMRA 3 PA; MO BENLYSTA INTRAVENOUS RECON SOLN 20 MG CUPRIMINE DEPEN TITRATABS ENBREL SUBCUTANEOUS KIT (8 per 28 49

58 Name ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.5) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK HUMIRA SUBCUTANEOUS KIT 20 MG/0.4 ML HUMIRA SUBCUTANEOUS KIT 40 MG/0.8 ML HUMIRA CROHN'S DIS START PCK (8 per 28 (4 per 28 (4 per 28 (2 per 28 (3.2 per 28 (4.8 per 80 HUMIRA PEN (3.2 per 28 HUMIRA PSORIASIS STARTER PACK (3.2 per 80 leflunomide ; QL (30 ORENCIA 3 PA; MO ORENCIA (WITH MALTOSE) 3 PA; MO OTEZLA 3 PA; MO OTEZLA STARTER 3 PA; MO RIDAURA OBSTETRICS / GYNECOLOGY Name ESTROGENS / PROGESTINS CAMILA DEPO-PROVERA INTRAMUSCULA R SOLUTION ERRIN ESTRACE VAGINAL estradiol oral estradiol transdermal estradiol valerate estradiolnorethindrone acet ; QL (4 per 28 estropipate JOLIVETTE LYZA medroxyprogesteron e intramuscular suspension medroxyprogesteron e oral MENEST MIMVEY MIMVEY LO NORA-BE norethindrone (contraceptive) norethindrone acetate progesterone micronized 50

59 Name MISCELLANEOUS OB/GYN clindamycin phosphate vaginal metronidazole vaginal MICONAZOLE-3 VAGINAL SUPPOSITORY terconazole tranexamic acid oral VANDAZOLE XULANE ORAL CONTRACEPTIVES / RELATED AGENTS AMETHIA AMETHYST APRI ARANELLE (28) AVIANE BALZIVA (28) BRIELLYN CRYSELLE (28) CYCLAFEM /35 (28) CYCLAFEM 7/7/7 (28) drospirenone-ethinyl estradiol ELLA EMOQUETTE ENPRESSE Name GIANVI (28) GILDAGIA INTROVALE JUNEL.5/30 (2) JUNEL /20 (2) JUNEL FE.5/30 (28) JUNEL FE /20 (28) KARIVA (28) KELNOR /35 (28) LARIN /20 (2) LARIN FE LEENA 28 LESSINA LEVONEST (28) levonorgestrelethinyl estrad oral tablets,dose pack,3 month LEVORA-28 LOMEDIA 24 FE LORYNA (28) LOW-OGESTREL (28) LUTERA (28) MARLISSA MICROGESTIN.5/30 (2) MICROGESTIN /20 (2) 5

60 Name MICROGESTIN FE.5/30 (28) MICROGESTIN FE /20 (28) MONONESSA (28) NECON 0.5/35 (28) NECON /35 (28) NECON /50 (28) NECON 0/ (28) NECON 7/7/7 (28) NORTREL 0.5/35 (28) NORTREL /35 (2) NORTREL /35 (28) NORTREL 7/7/7 (28) OCELLA OGESTREL (28) ORSYTHIA PIMTREA (28) PIRMELLA ORAL TABLET -35 MG- MCG PORTIA PREVIFEM QUASENSE RECLIPSEN (28) SPRINTEC (28) SRONYX Name TRI-LEGEST FE TRI-PREVIFEM (28) TRI-SPRINTEC (28) TRINESSA (28) TRIVORA (28) VELIVET TRIPHASIC REGIMEN (28) VESTURA (28) VYFEMLA (28) ZENCHENT (28) ZENCHENT FE ZOVIA /35E (28) ZOVIA /50E (28) OXYTOCICS methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS bacitracin ophthalmic bacitracinpolymyxin b ophthalmic ciprofloxacin ophthalmic erythromycin ophthalmic gatifloxacin 52

61 Name GENTAK OPHTHALMIC OINTMENT gentamicin ophthalmic drops gentamicin ophthalmic ointment levofloxacin ophthalmic NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic polymyxin b sulftrimethoprim tobramycin ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS betaxolol ophthalmic carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic Name CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic MISCELLANEOUS OPHTHALMOLOGICS azelastine ophthalmic cromolyn ophthalmic CYSTARAN epinastine RESTASIS ; QL (60 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ketorolac ophthalmic ORAL DRUGS FOR GLAUCOMA acetazolamide oral acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS dorzolamide 53

62 Name dorzolamide-timolol latanoprost travoprost (benzalkonium) STEROID-ANTIBIOTIC COMBINATIONS neomycinbacitracin-poly-hc neomycinpolymyxin-dexameth neomycinpolymyxin-hc ophthalmic STEROIDS dexamethasone sodium phosphate ophthalmic FML S.O.P. PRED MILD prednisolone acetate prednisolone sodium phosphate ophthalmic STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE S.O.P. tobramycindexamethasone sulfacetamideprednisolone SULFONAMIDES Name sulfacetamide sodium ophthalmic SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0. % apraclonidine brimonidine VASOCONSTRICTOR DECONGESTANTS naphazoline RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS ADRENALIN INJECTION SOLUTION MG/ML (:,000) (ML) cetirizine oral solution mg/ml desloratadine ; QL (30 diphenhydramine hcl injection solution diphenhydramine hcl oral elixir PA; MO EPIPEN 2 QL (4 per 30 EPIPEN 2-PAK ; QL (4 per 30 EPIPEN JR 2 QL (4 per 30 54

63 Name EPIPEN JR 2-PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet promethazine injection solution PULMONARY AGENTS acetylcysteine solution PA; MO ; QL (30 PA; MO ADEMPAS 3 PA; MO; LA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml PA; MO albuterol sulfate oral aminophylline intravenous solution 250 mg/0 ml ARCAPTA NEOHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (30 DOSES), 220 MCG (30 DOSES) ; QL (30 ; QL (30 Name ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (20 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (240 ; QL (60 ATROVENT HFA ; QL (25.8 budesonide inhalation PA; MO budesonide nasal ; QL (7.2 CINRYZE 3 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation PA; MO DALIRESP 2 PA; MO DULERA 2 PA; MO; QL (3 per 30 FIRAZYR 3 PA; MO flunisolide ; QL (50 fluticasone nasal ; QL (6 ipratropium bromide inhalation PA; MO 55

64 Name ipratropiumalbuterol PA; MO KALYDECO LETAIRIS 3 PA; MO; LA levalbuterol hcl inhalation solution for nebulization 0.3 mg/3 ml, 0.63 mg/3 ml,.25 mg/0.5 ml PA; MO metaproterenol montelukast OPSUMIT 3 PA; MO; LA PERFOROMIST 2 PA; MO PROAIR HFA ; QL (7 PULMICORT INHALATION SUSPENSION FOR NEBULIZATION MG/2 ML 2 PA; MO PULMOZYME 3 PA; MO QVAR ; QL (7.4 REVATIO INTRAVENOUS SEREVENT DISKUS 3 PA; MO ; QL (60 sildenafil PA; MO; QL (90 per 30 SPIRIVA WITH HANDIHALER ; QL (90 Name SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION 2 PA; MO; QL (0.2 per 30 2 PA; MO; QL (6.9 per 30 terbutaline oral terbutaline subcutaneous theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 2 hr 56 TRACLEER 3 PA; MO; LA triamcinolone acetonide nasal ; QL (6.5 TYVASO 3 PA; MO XOLAIR 3 PA; MO; LA; QL (6 per 28 zafirlukast UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate oxybutynin chloride oral

65 Name tolterodine trospium BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin finasteride oral tablet 5 mg tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS ammonium chloride 2 CYSTAGON ; LA ELMIRON potassium citrate oral tablet extended release 0 meq, 5 meq VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule ELIPHOS KLOR-CON 0 KLOR-CON 8 KLOR-CON M5 KLOR-CON M20 lactated ringers intravenous Name magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE potassium chloridd5-0.45%nacl intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride intravenous parenteral solution potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 40 meq/00 ml potassium chloride oral capsule, extended release potassium chloride oral tablet,er particles/crystals potassium chloride in 0.9%nacl potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l 2 57

66 Name potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride % nacl potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.3%nacl potassium chlorided5-0.9%nacl ringers intravenous sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % sodium chloride 5 % sodium lactate intravenous MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % 2 PA 2 PA 2 PA Name AMINOSYN II 7 % 2 PA AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE- FREE) CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%- D20W SULF-FREE CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 5%- D20W(SULFITE- FREE) CLINIMIX E 4.25%/D25W SUL FREE 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 58

67 Name CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE HEPATAMINE 8% 2 PA HEPATASOL 8 % 2 PA INTRALIPID INTRAVENOUS EMULSION 20 % IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 2 LIPOSYN III INTRAVENOUS EMULSION 0 %, 20 % NEPHRAMINE 5.4 % NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH PA; MO PA 2 PA 2 2 Name PLASMA-LYTE 48 PLASMA-LYTE A 2 PLASMA-LYTE-56 IN 5 % DEXTROSE PREMASOL 0 % PA PREMASOL 6 % 2 PA PROCALAMINE 3% PA TRAVASOL 0 % PA TROPHAMINE 0 % 2 PA TROPHAMINE 6% 2 PA VITAMINS / HEMATINICS PRENATAL VITAMIN sodium fluoride oral tablet 59

68 Index 8 8-MOP...34 A abacavir... abacavir-lamivudinezidovudine... ABELCET... ABILIFY...2 ABILIFY DISCMELT...2 ABILIFY MAINTENA...22 ABRAXANE...9 acamprosate...36 acarbose...39 acebutolol...29 acetaminophen-codeine...7 ACETASOL HC...38 acetazolamide...53 acetazolamide sodium...53 acetic acid...38 acetylcysteine...55 acitretin...33 ACTEMRA...49 ACTHIB (PF)...47 ACTIMMUNE...46 acyclovir..., 35 acyclovir sodium... ADACEL(TDAP ADOLESN/ADULT)(PF) 47 ADAGEN...36 adapalene...34 adefovir... ADEMPAS...55 ADRENALIN...54 ADVICOR...32 AFEDITAB CR...29 AFINITOR...9 AFINITOR DISPERZ...9 AGGRENOX...3 A-HYDROCORT...38 ALA-CORT...35 ALBENZA...5 albuterol sulfate...55 alclometasone...35 ALCOHOL PADS...39 ALDURAZYME...42 alendronate...36, 49 alfuzosin...57 ALIMTA...9 ALINIA...5 allopurinol...49 ALOPRIM...49 ALOXI...43 ALPHAGAN P...54 alprazolam...22 amantadine hcl... AMBISOME... amcinonide...35 AMETHIA...5 AMETHYST...5 amifostine crystalline...9 amikacin...5 amiloride...29 amiloride-hydrochlorothiazide...29 aminophylline...55 AMINOSYN 8.5 %- ELECTROLYTES...58 AMINOSYN II 0 %...58 AMINOSYN II 5 %...58 AMINOSYN II 7 %...58 AMINOSYN II 8.5 %...58 AMINOSYN II 8.5 %- ELECTROLYTES...58 AMINOSYN M 3.5 %...58 AMINOSYN-PF 0 %...58 AMINOSYN-PF 7 % (SULFITE-FREE)...58 amiodarone...28 AMITIZA...44 amitriptyline...22 amlodipine...29 amlodipine-atorvastatin...32 amlodipine-benazepril...29 ammonium chloride...57 ammonium lactate...34 AMNESTEEM...34 amoxapine...22 amoxicil-clarithromy-lansopraz...45 amoxicillin...7 amoxicillin-pot clavulanate...7 AMPHETAMINE SALT COMBO...22 amphotericin b... ampicillin...7 ampicillin sodium...7 ampicillin-sulbactam...7 AMPYRA...6 ANADROL anagrelide...36 anastrozole...9 ANDROGEL...42 ANDROXY...42 APEXICON E...35 APOKYN...6 apraclonidine...54 APRI...5 APTIOM...4, 5 APTIVUS... ARALAST NP...37 ARANELLE (28)...5 ARCALYST...46 ARCAPTA NEOHALER...55 ARRANON...9 ARZERRA...9 ASMANEX TWISTHALER55 atenolol...29 atenolol-chlorthalidone...29 ATGAM...47 atorvastatin...32 atovaquone...5 atovaquone-proguanil...5 ATRIPLA... atropine...43 ATROVENT HFA...55 AUGMENTIN...7 AVASTIN...9 AVELOX IN NACL (ISO- OSMOTIC)

69 AVIANE...5 AVITA...34 AVONEX...46 AVONEX ADMINISTRATION PACK...46 azacitidine...9 AZASAN...9 azathioprine...9 azelastine...38, 53 AZILECT...6 azithromycin...5 aztreonam...5 B BACIIM...5 bacitracin...5, 52 bacitracin-polymyxin b...52 baclofen...7 balsalazide...44 BALZIVA (28)...5 BANZEL...5 BARACLUDE..., 2 bcg vaccine, live (pf)...47 benazepril...29 benazepril-hydrochlorothiazide...29 BENLYSTA...49 benztropine...6 betamethasone dipropionate.35 betamethasone valerate...35 betamethasone, augmented...35 BETASERON...46 betaxolol...29, 53 bethanechol chloride...57 BETHKIS...5 bicalutamide...9 BICILLIN C-R...7 BICILLIN L-A...7 BICNU...9 bisoprolol fumarate...29 bisoprolol-hydrochlorothiazide...29 bleomycin...9 BLEPHAMIDE...54 BLEPHAMIDE S.O.P...54 BOOSTRIX TDAP...47 BOSULIF...9 BOTOX...48 BRIELLYN...5 BRILINTA...3 brimonidine...54 BRINTELLIX...22 bromfenac...53 bromocriptine...6 budesonide...44, 55 bumetanide...29 buprenorphine...7 buprenorphine-naloxone...20 BUPROBAN...38 bupropion hcl...22 buspirone...22 BUSULFEX...9 butorphanol tartrate...20 BYDUREON...39 BYETTA...40 C cabergoline...42 calcipotriene...33 calcipotriene-betamethasone 33 calcitonin (salmon)...42 calcitriol...33, 42 calcium acetate...57 CAMILA...50 CANASA...44 CANCIDAS... candesartan...29 candesartan-hydrochlorothiazid...29 CAPASTAT...5 CAPRELSA...9, 0 captopril...29 captopril-hydrochlorothiazide...29 CARAC...34 CARAFATE...45 CARBAGLU...37 carbamazepine...5 carbidopa...6 carbidopa-levodopa...6 carbidopa-levodopaentacapone...6 carboplatin...0 CARIMUNE NF NANOFILTERED...48 carteolol...53 CARTIA XT...29 carvedilol...29 CAYSTON...5 cefaclor...4 cefadroxil...4 cefazolin...4 cefazolin in dextrose (iso-os)..4 cefdinir...4 cefditoren pivoxil...4 cefepime...4 cefotaxime...4 cefotetan...4 cefoxitin...4 cefoxitin in dextrose, iso-osm.4 cefpodoxime...4 cefprozil...4 ceftazidime...4 ceftriaxone...4 cefuroxime axetil...4 cefuroxime sodium...4 CELEBREX...20 CELLCEPT...0 CELLCEPT INTRAVENOUS...0 CELONTIN...5 cephalexin...4 CEREZYME...42 CERVARIX VACCINE (PF)...48 CESAMET...44 cetirizine...54 cevimeline...37 CHANTIX...38 CHANTIX CONTINUING MONTH BOX...38 CHANTIX CONTINUING MONTH PAK...38 CHANTIX STARTING MONTH BOX

70 CHANTIX STARTING MONTH PAK...38 CHEMET...37 CHENODAL...44 chloramphenicol sod succinate...5 chlorhexidine gluconate...38 chloroquine phosphate...5 chlorothiazide...29 chlorothiazide sodium...29 chlorpromazine...22 chlorthalidone...29 CHOLESTYRAMINE LIGHT...32 chorionic gonadotropin, human...42 ciclopirox...35 cidofovir...2 cilostazol...3 cimetidine...45 CINRYZE...55 CIPRODEX...38 ciprofloxacin...8, 52 ciprofloxacin (mixture)...8 ciprofloxacin in 5 % dextrose.8 cisplatin...0 citalopram...22 cladribine...0 CLARAVIS...34 clarithromycin...5 clindamycin hcl...5 clindamycin in dextrose 5 %..5 CLINDAMYCIN PEDIATRIC...5 clindamycin phosphate...5, 34, 5 clindamycin-benzoyl peroxide...34 CLINIMIX 5%/D5W SULFITE FREE...58 CLINIMIX 5%/D25W SULFITE-FREE...58 CLINIMIX 2.75%/D5W SULFIT FREE...58 CLINIMIX 4.25%/D0W SULF FREE...58 CLINIMIX 4.25%/D5W SULFIT FREE...37 CLINIMIX 4.25%-D20W SULF-FREE...58 CLINIMIX 4.25%-D25W SULF-FREE...58 CLINIMIX 5%- D20W(SULFITE-FREE)..58 CLINIMIX E 2.75%/D0W SUL FREE...37 CLINIMIX E 2.75%/D5W SULF FREE...37 CLINIMIX E 4.25%/D25W SUL FREE...58 CLINIMIX E 4.25%/D5W SULF FREE...59 CLINIMIX E 5%/D5W SULFIT FREE...59 CLINIMIX E 5%/D20W SULFIT FREE...59 CLINIMIX E 5%/D25W SULFIT FREE...59 clobetasol...35 clobetasol-emollient...36 CLOLAR...0 clomipramine...22 clonazepam...5 clonidine...29 clonidine hcl...22, 29 clopidogrel...3 clorazepate dipotassium...22 CLORPRES...29 clotrimazole..., 35 clotrimazole-betamethasone.35 clozapine...22 COARTEM...5 codeine sulfate...7 colchicine-probenecid...49 COLCRYS...49 colestipol...33 colistin (colistimethate na)...5 COLOCORT...44 COMBIVENT RESPIMAT.55 COMETRIQ...0 COMPLERA...2 COMPRO...44 COMVAX (PF)...48 CONSTULOSE...44 COPAXONE...6 CORTIFOAM...44 cortisone...38 CREON...44 CRIXIVAN...2 cromolyn...44, 53, 55 CRYSELLE (28)...5 CUBICIN...5 CUPRIMINE...49 CYCLAFEM /35 (28)...5 CYCLAFEM 7/7/7 (28)...5 cyclobenzaprine...7 cyclophosphamide...0 CYCLOSET...40 cyclosporine...0 cyclosporine modified...0 CYSTADANE...44 CYSTAGON...57 CYSTARAN...53 cytarabine...0 cytarabine (pf)...0 D d0 % & 0.45 % sodium chloride...37 d2.5 %-0.45 % sodium chloride...37 d5 % and 0.9 % sodium chloride...37 d5 %-0.45 % sodium chloride...37 dacarbazine...0 DALIRESP...55 danazol...42 dantrolene...7 dapsone...5 DAPTACEL (DTAP PEDIATRIC) (PF)...48 DARAPRIM...5 daunorubicin...0 decitabine

71 demeclocycline...8 DEMSER...29 DENAVIR...35 DEPEN TITRATABS...49 DEPO-PROVERA...50 desipramine...22 desloratadine...54 desmopressin...42 desonide...36 desoximetasone...36 dexamethasone...39 DEXAMETHASONE INTENSOL...39 dexamethasone sodium phosphate...39, 54 dexmethylphenidate...22 dexrazoxane...9 dextroamphetamine...22 dextroamphetamineamphetamine...22 dextrose 0 % & 0.2 % nacl.37 dextrose 0 % in water (d0w)...37 dextrose 5 % in water (d5w) 37 dextrose 5 %-lactated ringers37 dextrose 5%-0.2 % sod chloride...37 dextrose 5%-0.3 % sod.chloride...37 diazepam...5, 22 DIAZEPAM INTENSOL...22 DIBENZYLINE...30 diclofenac potassium...20 diclofenac sodium...20, 34, 53 diclofenac-misoprostol...20 dicloxacillin...7 dicyclomine...43 didanosine...2 diflorasone...36 diflunisal...20 digoxin...3 dihydroergotamine...6 DILANTIN...5 diltiazem hcl...30 DILT-XR...30 DIPENTUM...44 diphenhydramine hcl...54 diphenoxylate-atropine...43 dipyridamole...32 disulfiram...37 divalproex...5 DOCEFREZ...0 docetaxel...0 donepezil...7 DORIBAX...6 dorzolamide...53 dorzolamide-timolol...54 doxazosin...30 doxepin...23 doxercalciferol...42 DOXIL...0 doxorubicin...0 doxycycline hyclate...8 doxycycline monohydrate...8 dronabinol...44 drospirenone-ethinyl estradiol...5 DROXIA...0 DULERA...55 duloxetine...23 DURAMORPH (PF)...8 DUTOPROL...30 E E.E.S E.E.S. GRANULES...5 econazole...35 EDURANT...2 EFFIENT...32 EGRIFTA...46 ELAPRASE...42 ELELYSO...42 ELIGARD...0 ELIPHOS...57 ELIQUIS...32 ELITEK...9 ELLA...5 ELMIRON...57 EMCYT...0 EMEND...44 EMOQUETTE...5 EMSAM...23 EMTRIVA...2 enalapril maleate...30 enalapril-hydrochlorothiazide...30 ENBREL...49, 50 ENBREL SURECLICK...50 ENDOCET...8 ENDODAN...8 ENGERIX-B (PF)...48 ENGERIX-B PEDIATRIC (PF)...48 enoxaparin...32 ENPRESSE...5 entacapone...6 ENULOSE...44 epinastine...53 EPIPEN...54 EPIPEN 2-PAK...54 EPIPEN JR...54 EPIPEN JR 2-PAK...55 epirubicin...0 EPITOL...5 EPIVIR...2 EPIVIR HBV...2 eplerenone...30 eprosartan...30 EPZICOM...2 ERBITUX...0 ergoloid...23 ERGOMAR...6 ERIVEDGE...0 ERRIN...50 ERWINAZE...0 ERY PADS...34 ERYPED ERYPED ERY-TAB...5 ERYTHROCIN...5 ERYTHROCIN (AS STEARATE)...5 erythromycin...5, 52 erythromycin ethylsuccinate...5 erythromycin with ethanol

72 erythromycin-benzoyl peroxide...34 erythromycin-sulfisoxazole...5 escitalopram oxalate...23 esomeprazole sodium...45 ESTRACE...50 estradiol...50 estradiol valerate...50 estradiol-norethindrone acet.50 estropipate...50 eszopiclone...23 ethambutol...6 ethosuximide...5 etidronate disodium...37 etodolac...20 ETOPOPHOS...0 etoposide...0 EXELON...7 exemestane...0 EXJADE...37 F FABRAZYME...42 famciclovir...2 famotidine...45 famotidine (pf)...45 famotidine (pf)-nacl (iso-os)45 FANAPT...23 FARESTON...0 FASLODEX...0 FAZACLO...23 felbamate...5 felodipine...30 fenofibrate...33 fenofibrate micronized...33 fenofibrate nanocrystallized.33 fenofibric acid (choline)...33 fenoprofen...20 fentanyl citrate...8 fentanyl patches...8 FERRIPROX...37 FETZIMA...23 finasteride...57 FIRAZYR...55 FIRMAGON KIT W DILUENT SYRINGE... flavoxate...56 flecainide...28 fluconazole... fluconazole in dextrose(iso-o) flucytosine... fludarabine... fludrocortisone...39 flunisolide...55 fluocinolone...36 fluocinolone acetonide oil...38 fluocinonide...36 FLUOCINONIDE-E...36 fluorouracil..., 34 fluoxetine...23, 24 fluphenazine decanoate...24 fluphenazine hcl...24 flurbiprofen...20 flurbiprofen sodium...53 flutamide... fluticasone...36, 55 fluvastatin...33 fluvoxamine...24 FML S.O.P FOLOTYN... fomepizole...48 fondaparinux...32 FORTEO...49 FORTICAL...42 foscarnet...2 fosinopril...30 fosinopril-hydrochlorothiazide...30 fosphenytoin...5 furosemide...30 FUSILEV...9 FUZEON...2 FYCOMPA...5 G gabapentin...5 GABITRIL...5 GABLOFEN...7 galantamine...7 GAMASTAN S/D...48 GAMUNEX-C...48 ganciclovir sodium...2 GARDASIL (PF)...48 gatifloxacin...52 gauze pads 2 x GAVILYTE-C...44 GAVILYTE-G...44 GAVILYTE-N...44 gemcitabine... gemfibrozil...33 GENERLAC...44 GENGRAF... GENTAK...53 gentamicin...6, 35, 53 gentamicin in nacl (iso-osm)..6 gentamicin sulfate (pf)...6 GEODON...24 GIANVI (28)...5 GILDAGIA...5 GILENYA...7 GILOTRIF... GLEEVEC... glimepiride...40 glipizide...40 glipizide-metformin...40 GLUCAGEN...40 GLUCAGEN HYPOKIT...40 GLUCAGON EMERGENCY...40 glycopyrrolate...43 granisetron...44 granisetron (pf)...44 GRANISOL...44 griseofulvin microsize... griseofulvin ultramicrosize... guanidine...24 H HALAVEN... halobetasol propionate...36 haloperidol...24 haloperidol decanoate...24 haloperidol lactate...24 HAVRIX (PF)...48 heparin (porcine)...32 heparin (porcine) in 5 % dex 32 heparin (porcine) in nacl (pf)32 HEPATAMINE 8%

73 HEPATASOL 8 %...59 HERCEPTIN... HEXALEN... HUMALOG...40 HUMALOG KWIKPEN...40 HUMALOG MIX HUMALOG MIX KWIKPEN...40 HUMALOG MIX HUMALOG MIX KWIKPEN...40 HUMIRA...50 HUMIRA CROHN'S DIS START PCK...50 HUMIRA PEN...50 HUMIRA PSORIASIS STARTER PACK...50 HUMULIN 70/ HUMULIN 70/30 KWIKPEN...40 HUMULIN 70/30 PEN...40 HUMULIN N...40 HUMULIN N KWIKPEN...40 HUMULIN N PEN...40 HUMULIN R...40 HUMULIN R U hydralazine...30 hydrochlorothiazide...30 hydrocodone-acetaminophen8 hydrocodone-ibuprofen...8 hydrocortisone...36, 39, 44 hydrocortisone butyrate...36 hydrocortisone butyr-emollient...36 hydrocortisone valerate...36 hydrocortisone-acetic acid...38 hydromorphone...8 hydromorphone (pf)...8 hydroxychloroquine...6 hydroxyurea... hydroxyzine hcl...55 I ibandronate...49 ibuprofen...20 ibuprofen-oxycodone...8 idarubicin... ifosfamide... ILARIS (PF)...46 IMBRUVICA... imipenem-cilastatin...6 imipramine hcl...24 imipramine pamoate...24 imiquimod...34 IMOVAX RABIES VACCINE (PF)...48 INCRELEX...37 indapamide...30 INFANRIX (DTAP) (PF)...48 INLYTA... insulin pen needle...40 insulin syringe (disp) u ml...4 insulin syringe (disp) u-00 ml...4 insulin syringe (disp) u-00 /2 ml...4 INTELENCE...2 INTRALIPID...59 INTRON A...46 INTROVALE...5 INVANZ...6 INVEGA...24 INVEGA SUSTENNA...24 INVIRASE...2 INVOKANA...4 IONOSOL-B IN D5W...59 IONOSOL-MB IN D5W...59 IPOL...48 ipratropium bromide...38, 55 ipratropium-albuterol...56 irbesartan...30 irbesartan-hydrochlorothiazide...30 irinotecan... ISENTRESS...2 ISOLYTE-P IN 5 % DEXTROSE...59 ISOLYTE-S...59 isoniazid...6 isosorbide dinitrate...33 isosorbide mononitrate...33 isradipine...30 ISTODAX... itraconazole... IXEMPRA... IXIARO (PF)...48 J JAKAFI... JANTOVEN...32 JANUMET...4 JANUMET XR...4 JANUVIA...4 JENTADUETO...4 JEVTANA... JOLIVETTE...50 JUNEL.5/30 (2)...5 JUNEL /20 (2)...5 JUNEL FE.5/30 (28)...5 JUNEL FE /20 (28)...5 JUXTAPID...33 K KADCYLA... KALETRA...2 KALYDECO...56 KARIVA (28)...5 KELNOR /35 (28)...5 KEPIVANCE...9 ketoconazole..., 35 KETODAN KIT...35 ketoprofen...2 ketorolac...53 KIONEX...37 KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KUVAN...42 KYNAMRO...33 L labetalol...30 lactated ringers...36, 57 lactulose...44 LAMISIL... lamivudine...2 lamivudine-zidovudine

74 lamotrigine...5 LANOXIN...3 lansoprazole...45 LANTUS...4 LANTUS SOLOSTAR...4 LARIN /20 (2)...5 LARIN FE...5 latanoprost...54 LATUDA...24, 25 LEENA leflunomide...50 LESSINA...5 LETAIRIS...56 letrozole... leucovorin calcium...9 LEUKERAN... LEUKINE...46 leuprolide... levalbuterol hcl...56 LEVEMIR...4 LEVEMIR FLEXPEN...4 LEVEMIR FLEXTOUCH...4 levetiracetam...5 levobunolol...53 levocarnitine...37 levocarnitine (with sugar)...37 levocetirizine...55 levofloxacin...8, 53 levofloxacin in d5w...8 LEVONEST (28)...5 levonorgestrel-ethinyl estrad 5 LEVORA levorphanol tartrate...8 levothyroxine...43 LEVOXYL...43 LEXIVA...2 LIALDA...44 lidocaine...34 lidocaine (pf)...34 lidocaine hcl...34, 35 lidocaine-prilocaine...35 lindane...36 LINZESS...44 LIORESAL...7 liothyronine...43 LIPOSYN III...59 lisinopril...30 lisinopril-hydrochlorothiazide...30 lithium carbonate...25 lithium citrate...25 LOMEDIA 24 FE...5 lomustine...2 loperamide...43 lorazepam...25 LORAZEPAM INTENSOL.25 LORCET (HYDROCODONE)...9 LORCET HD...9 LORCET PLUS...9 LORTAB LORTAB LORTAB LORYNA (28)...5 losartan...30 losartan-hydrochlorothiazide 30 LOTRONEX...44 lovastatin...33 LOW-OGESTREL (28)...5 loxapine succinate...25 LUMIZYME...42 LUPRON DEPOT...2 LUPRON DEPOT (3 MONTH)...2 LUPRON DEPOT (4 MONTH)...2 LUPRON DEPOT (6 MONTH)...2 LUPRON DEPOT-PED...2 LUTERA (28)...5 LYRICA...5 LYSODREN...2 LYZA...50 M MACRODANTIN...8 mafenide acetate...35 magnesium sulfate...57 malathion...36 maprotiline...25 MARLISSA...5 MARPLAN...25 MATULANE...2 MATZIM LA...30 meclizine...44 meclofenamate...2 medroxyprogesterone...50 mefenamic acid...2 mefloquine...6 megestrol...2 MEKINIST...2 meloxicam...2 melphalan...2 MENACTRA (PF)...48 MENEST...50 MENOMUNE - A/C/Y/W-35 (PF)...48 MENVEO A-C-Y-W-35-DIP (PF)...48 mercaptopurine...2 meropenem...6 mesalamine with cleansing wipe...44 mesna...9 MESNEX...9 MESTINON...7 MESTINON TIMESPAN...7 METADATE ER...25 metaproterenol...56 metformin...4 methadone...9 methamphetamine...25 methazolamide...53 methenamine hippurate...8 methimazole...39 METHITEST...42 methotrexate sodium...2 methotrexate sodium (pf)...2 methoxsalen rapid...34 methyclothiazide...30 methyldopa...30 methylergonovine...52 methylphenidate...25 methylprednisolone...39 methylprednisolone acetate

75 methylprednisolone sodium succ...39 metipranolol...53 metoclopramide hcl...44 metolazone...30 metoprolol succinate...30 metoprolol ta-hydrochlorothiaz...30 metoprolol tartrate...30 metronidazole...6, 34, 5 metronidazole in nacl (iso-os) 6 mexiletine...29 MIACALCIN...42 MICONAZOLE MICROGESTIN.5/30 (2) 5 MICROGESTIN /20 (2)...5 MICROGESTIN FE.5/30 (28)...52 MICROGESTIN FE /20 (28)...52 midodrine...37 MIGERGOT...6 MILLIPRED...39 MIMVEY...50 MIMVEY LO...50 minocycline...8 minoxidil...30 mirtazapine...25 misoprostol...45 mitomycin...2 mitoxantrone...2 M-M-R II (PF)...48 modafinil...25 MODERIBA...2 MODERIBA DOSE PACK...2 moexipril...30 moexipril-hydrochlorothiazide...30 mometasone...36 MONONESSA (28)...52 montelukast...56 morphine...9 morphine concentrate...9 moxifloxacin...8 MOZOBIL...47 mupirocin...35 mupirocin calcium...35 MUSTARGEN...2 MYALEPT...42 MYCAMINE... mycophenolate mofetil...2 mycophenolate sodium...2 MYORISAN...34 MYOZYME...42 N nabumetone...2 nadolol...3 nadolol-bendroflumethiazide3 nafcillin...7 nafcillin in dextrose iso-osm..7 NAGLAZYME...42 nalbuphine...2 naloxone...2 naltrexone...2 NAMENDA...7 NAMENDA TITRATION PAK...7 naphazoline...54 naproxen...2 naproxen sodium...2 naratriptan...6 NATACYN...53 nateglinide...4 NEBUPENT...6 NECON 0.5/35 (28)...52 NECON /35 (28)...52 NECON /50 (28)...52 NECON 0/ (28)...52 NECON 7/7/7 (28)...52 needles, insulin disp.,safety..4 nefazodone...25 neomycin...6 neomycin-bacitracin-poly-hc54 neomycin-bacitracinpolymyxin...53 neomycin-polymyxin b gu...36 neomycin-polymyxindexameth...54 neomycin-polymyxingramicidin...53 neomycin-polymyxin-hc.38, 54 NEPHRAMINE 5.4 %...59 NEULASTA...47 NEUMEGA...47 NEUPOGEN...47 NEUPRO...6 nevirapine...2 NEXAVAR...2 niacin...33 nicardipine...3 NICOTROL...38 NICOTROL NS...38 NIFEDICAL XL...3 nifedipine...3 NILANDRON...2 nimodipine...3 nisoldipine...3 NITRO-BID...33 nitrofurantoin...8 nitrofurantoin macrocrystal...8 nitrofurantoin monohyd/mcryst...8 nitroglycerin...33 NITROSTAT...33 nizatidine...46 NORA-BE...50 norethindrone (contraceptive)...50 norethindrone acetate...50 NORMOSOL-M IN 5 % DEXTROSE...59 NORMOSOL-R IN 5 % DEXTROSE...57 NORMOSOL-R PH NORTREL 0.5/35 (28)...52 NORTREL /35 (2)...52 NORTREL /35 (28)...52 NORTREL 7/7/7 (28)...52 nortriptyline...25 NORVIR...2 NOVAREL...43 NOVOLOG...4 NOVOLOG FLEXPEN...4 NOVOLOG MIX

76 NOVOLOG MIX FLEXPEN...4 NOVOLOG PENFILL...4 NOXAFIL... NUEDEXTA...7 NULOJIX...2 NYAMYC...35 nystatin..., 35 nystatin-triamcinolone...35 NYSTOP...35 O OCELLA...52 octreotide acetate...2 ofloxacin...8, 38, 53 OGESTREL (28)...52 olanzapine...25 olanzapine-fluoxetine...25 OLYSIO...2 omega-3 acid ethyl esters...33 omeprazole...46 omeprazole-sodium bicarbonate...46 OMNITROPE...47 ONCASPAR...2 ondansetron...44 ondansetron hcl...44 ondansetron hcl (pf)...44 ONFI...5 OPSUMIT...56 ORAP...25 ORENCIA...50 ORENCIA (WITH MALTOSE)...50 ORFADIN...37 ORSYTHIA...52 OTEZLA...50 OTEZLA STARTER...50 oxacillin...7 oxacillin in dextrose(iso-osm) 7 oxaliplatin...2 oxandrolone...43 oxaprozin...2 oxazepam...25 oxcarbazepine...5 OXSORALEN...34 oxybutynin chloride...56 oxycodone...9, 20 oxycodone-acetaminophen...20 oxycodone-aspirin...20 oxymorphone...20 P PACERONE...29 paclitaxel...2 pamidronate...43 PANRETIN...34 pantoprazole...46 paricalcitol...43 paromomycin...6 paroxetine hcl...25, 26 PASER...6 PAXIL...26 PEDI-DRI...35 PEDVAX HIB (PF)...48 peg 3350-electrolytes...44 PEGANONE...5 PEGASYS...47 PEGASYS CONVENIENCE PACK...47 PEGASYS PROCLICK...47 PEGINTRON...47 PEGINTRON REDIPEN...47 penicillin g potassium...7 penicillin g procaine...7 penicillin g sodium...7 penicillin v potassium...7 PENTAM...6 PENTASA...44 pentoxifylline...32 PERFOROMIST...56 perindopril erbumine...3 PERIOGARD...38 PERJETA...2 permethrin...36 perphenazine...26 perphenazine-amitriptyline...26 PFIZERPEN-G...7 phenelzine...26 phenobarbital...5 phenytoin...5 phenytoin sodium...5 phenytoin sodium extended..5 PHOSPHOLINE IODIDE...53 pilocarpine hcl...37, 53 PIMTREA (28)...52 pindolol...3 pioglitazone...4 pioglitazone-glimepiride...4 pioglitazone-metformin...4 piperacillin-tazobactam...8 PIRMELLA...52 piroxicam...2 PLASMA-LYTE PLASMA-LYTE A...59 PLASMA-LYTE-56 IN 5 % DEXTROSE...59 podofilox...34 polyethylene glycol polymyxin b sulfate...6 polymyxin b sulf-trimethoprim...53 POMALYST...2 PORTIA...52 potassium chlorid-d5-0.45%nacl...57 potassium chloride...57 potassium chloride in 0.9%nacl...57 potassium chloride in 5 % dex...57 potassium chloride in lr-d potassium chloride-0.45 % nacl...58 potassium chloride-d5-0.2%nacl...58 potassium chloride-d5-0.3%nacl...58 potassium chloride-d5-0.9%nacl...58 potassium citrate...57 POTIGA...5 pramipexole...6 pravastatin...33 prazosin...3 PRED MILD...54 prednicarbate

77 prednisolone acetate...54 prednisolone sodium phosphate...39, 54 prednisone...39 PREDNISONE INTENSOL 39 PREMASOL 0 %...59 PREMASOL 6 %...59 PRENATAL VITAMIN...59 PREVALITE...33 PREVIFEM...52 PREZISTA...3 PRIFTIN...6 primaquine...6 primidone...5 PRIMSOL...8 PRISTIQ...26 PRIVIGEN...48 PROAIR HFA...56 probenecid...49 procainamide...29 PROCALAMINE 3%...59 PROCENTRA...26 prochlorperazine...45 prochlorperazine edisylate...45 prochlorperazine maleate...45 PROCRIT...47 PROCTO-PAK...45 PROCTOZONE-HC...45 progesterone micronized...50 PROGLYCEM...4 PROGRAF...2 PROLASTIN-C...37 PROLEUKIN...47 PROLIA...49 PROMACTA...32 promethazine...55 propafenone...29 propranolol...3 propranolol-hydrochlorothiazid...3 propylthiouracil...39 PROQUAD (PF)...48 PROTOPIC...34 protriptyline...26 PRUDOXIN...34 PULMICORT...56 PULMOZYME...56 pyrazinamide...6 pyridostigmine bromide...7 Q QUASENSE...52 quetiapine...26 quinapril...3 quinapril-hydrochlorothiazide...3 quinidine gluconate...29 quinidine sulfate...29 quinine sulfate...6 QVAR...56 R RABAVERT (PF)...48 rabeprazole...46 RAGWITEK...48 raloxifene...49 ramipril...3 RANEXA...33 ranitidine hcl...46 RAPAMUNE...2, 3 RAVICTI...37 REBIF (WITH ALBUMIN).47 REBIF REBIDOSE...47 REBIF TITRATION PACK.47 RECLIPSEN (28)...52 RECOMBIVAX HB (PF)...49 RECTIV...45 REGRANEX...34 RELENZA DISKHALER...3 RELISTOR...45 REMICADE...45 REMODULIN...3 RENVELA...37 repaglinide...42 REPREXAIN...20 RESCRIPTOR...3 RESTASIS...53 RETROVIR...3 REVATIO...56 REVLIMID...3 REYATAZ...3 RIBAPAK DOSE PACK...3 RIBASPHERE...3 ribavirin...3 RIDAURA...50 rifabutin...6 rifampin...6 riluzole...37 rimantadine...3 ringers...36, 58 RIOMET...42 risedronate...49 RISPERDAL CONSTA...26 risperidone...26, 27 RITUXAN...3 rivastigmine tartrate...7 rizatriptan...6 ropinirole...6 ROTARIX...49 ROTATEQ VACCINE...49 ROZEREM...27 S SABRIL...5 SAIZEN...47 SAIZEN CLICK.EASY...47 SAMSCA...43 SANDOSTATIN LAR DEPOT...3 SANTYL...36 SAPHRIS...27 SAPHRIS (BLACK CHERRY)...27 selegiline hcl...6 selenium sulfide...33 SELZENTRY...3 SENSIPAR...43 SEREVENT DISKUS...56 SEROQUEL XR...27 sertraline...27, 28 SIGNIFOR...3 sildenafil...56 silver sulfadiazine...34 SIMULECT...3 simvastatin...33 sirolimus...3 SIRTURO...6 sodium chloride...38, 58 69

78 sodium chloride 0.45 %...58 sodium chloride 0.9 %...38 sodium chloride 3 %...58 sodium chloride 5 %...58 sodium fluoride...59 sodium lactate...58 sodium phenylbutyrate...38 SODIUM POLYSTYRENE (SORB FREE)...38 SOLTAMOX...3 SOMAVERT...43 SORINE...29 sotalol...29 SOTALOL AF...29 SOVALDI...3 spinosad...36 SPIRIVA WITH HANDIHALER...56 spironolactone...3 spironolacton-hydrochlorothiaz...3 SPORANOX... SPRINTEC (28)...52 SPRYCEL...3 SRONYX...52 SSD...34 stavudine...3 STIVARGA...3 STRATTERA...28 streptomycin...6 STRIBILD...3 STROMECTOL...6 SUCRAID...45 sucralfate...46 sulfacetamide sodium...54 sulfacetamide sodium (acne) 35 sulfacetamide-prednisolone..54 sulfadiazine...8 sulfamethoxazole-trimethoprim...8 SULFAMYLON...35 sulfasalazine...45 SULFAZINE EC...45 sulindac...2 sumatriptan...6 sumatriptan succinate...6 SUPRAX...4 SURMONTIL...28 SUSTIVA...3 SUTENT...3 SYLATRON...47 SYLVANT...3 SYMBICORT...56 SYMLINPEN SYMLINPEN SYNAGIS...3 SYNAREL...43 SYNERCID...6 SYNRIBO...3 SYPRINE...38 T TABLOID...3 tacrolimus...3 TAFINLAR...3 TAMIFLU...3 tamoxifen...3 tamsulosin...57 TARCEVA...3 TARGRETIN...3 TASIGNA...3 TAZORAC...34 TAZTIA XT...3 TECFIDERA...7 TEFLARO...4 TEGRETOL XR...6 telmisartan...3 telmisartan-amlodipine...3 telmisartan-hydrochlorothiazid...3 temazepam...28 terazosin...3 terbinafine... terbutaline...56 terconazole...5 testosterone cypionate...43 testosterone enanthate...43 tetanus toxoid,adsorbed (pf).49 tetanus-diphtheria toxoids-td 49 tetracycline...8 THALOMID...3 theophylline...56 THIOLA...38 thioridazine...28 thiothixene...28 THYROLAR THYROLAR-/ THYROLAR-/ THYROLAR THYROLAR tiagabine...6 TIKOSYN...29 timolol maleate...3, 53 tinidazole...6 TIVICAY...3 tizanidine...7 tobramycin...53 tobramycin in % nacl...6 tobramycin in 0.9 % nacl...6 tobramycin sulfate...6 tobramycin-dexamethasone..54 tolazamide...42 tolbutamide...42 tolmetin...2 tolterodine...57 topiramate...6 TOPOSAR...3 topotecan...3 TORISEL...3 torsemide...3 TRACLEER...56 TRADJENTA...42 tramadol...2 tramadol-acetaminophen...2 trandolapril...3 tranexamic acid...32, 5 TRANSDERM-SCOP...45 tranylcypromine...28 TRAVASOL 0 %...59 travoprost (benzalkonium)...54 trazodone...28 TREANDA...4 TRECATOR...6 TRELSTAR...4 TRELSTAR DEPOT...4 TRELSTAR LA

79 tretinoin...34 tretinoin (chemotherapy)...4 triamcinolone acetonide 36, 38, 39, 56 triamterene-hydrochlorothiazid...3 TRIDERM...36 trifluoperazine...28 trifluridine...53 TRI-LEGEST FE...52 TRILYTE WITH FLAVOR PACKETS...45 trimethoprim...8 TRINESSA (28)...52 TRI-PREVIFEM (28)...52 TRISENOX...4 TRI-SPRINTEC (28)...52 TRIVORA (28)...52 TROPHAMINE 0 %...59 TROPHAMINE 6%...59 trospium...57 TRUVADA...3 TWINRIX (PF)...49 TYGACIL...6 TYKERB...4 TYPHIM VI...49 TYSABRI...7 TYVASO...56 TYZEKA...3 TYZINE...38 U UCERIS...45 ULORIC...49 UNITHROID...43 ursodiol...45 UVADEX...34 V valacyclovir...3 VALCYTE...3 valproate sodium...6 valproic acid...6 valproic acid (as sodium salt)...6 valsartan-hydrochlorothiazide...3 vancomycin...9 VANDAZOLE...5 VAQTA (PF)...49 VARIVAX (PF)...49 VECAMYL...33 VECTIBIX...4 VELCADE...4 VELIVET TRIPHASIC REGIMEN (28)...52 venlafaxine...28 verapamil...3 VERIPRED VERSACLOZ...28 VESTURA (28)...52 VGO VGO VGO VICODIN...20 VICODIN ES...20 VICODIN HP...20 VICTRELIS...3 VIDEX 2 GRAM PEDIATRIC...3 VIIBRYD...28 VIMPAT...6 vinblastine...4 vincristine...4 vinorelbine...4 VIOKACE...45 VIRACEPT...3 VIRAMUNE XR...3 VIRAZOLE...3 VIREAD...3 VOLTAREN GEL...2 voriconazole... VOTRIENT...4 VPRIV...43 VYFEMLA (28)...52 W warfarin...32 water for irrigation, sterile...38 WELCHOL...33 X XALKORI...4 XARELTO...32 XENAZINE...7 XGEVA...9 XIFAXAN...6, 7 XOLAIR...56 XTANDI...4 XULANE...5 XYREM...28 Y YERVOY...4 YF-VAX (PF)...49 Z zafirlukast...56 zaleplon...28 ZALTRAP...4 ZAMICET...20 ZANOSAR...4 ZAVESCA...43 ZELBORAF...4 ZEMPLAR...43 ZENATANE...34 ZENCHENT (28)...52 ZENCHENT FE...52 ZENPEP...45 ZENZEDI...28 ZETIA...33 ZIAGEN...4 zidovudine...4 ziprasidone hcl...28 ZIRGAN...53 zoledronic acid...43 zoledronic acid-mannitol-water...38 ZOLINZA...4 zolmitriptan...6 zolpidem...28 zonisamide...6 ZORTRESS...4 ZOSTAVAX (PF)...49 ZOVIA /35E (28)...52 ZOVIA /50E (28)...52 ZOVIRAX...35 ZUBSOLV...2 ZYCLARA...34 ZYKADIA...4 ZYTIGA...4 7

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82 With Express Scripts Medicare, you will have access to over 68,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care or Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) pharmacy, or through our convenient home delivery service. You must use network pharmacies to fill your prescriptions to get the most of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply. This formulary was updated on 08/06/204. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. 204 Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. F0HP3X5B EME969 CRP